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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700769
Report Date: 07/20/2022
Date Signed: 07/20/2022 03:49:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220624123206
FACILITY NAME:DELTA MANORFACILITY NUMBER:
392700769
ADMINISTRATOR:ZUBIATE, LEAHFACILITY TYPE:
735
ADDRESS:1201 W. SWAIN ROADTELEPHONE:
(805) 242-0135
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:14CENSUS: 11DATE:
07/20/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tanya MongeTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility is in disrepair
Facility does not provide a safe environment for residents

INVESTIGATION FINDINGS:
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On 7-20-22 at 1:30pm, Licensing Program Analysts (LPAs) Michael Bilger and Renee Campbell arrived unannounced to deliver findings for the complaint allegations listed above. LPA met with Tanya Monge and explained the purpose of the visit. Administrator Leah Zubiate was not present and gave permission for Tanya to sign in her absence. During this investigation, LPA conducted a facility observation on 7-1-22, and interviewed facility manager on 7-1-22. LPA's also conducted an additional faciilty observation and additional staff interviews on 7-20-22. LPA also interviewed Administrator and reviewed facility file documentation including gardening service records and fire clearance report.

Allegation #1: Facility is in disrepair. LPA conducted facility observation including resident rooms, bathrooms, common areas, kitchen, laundry area, storage room, and front and backyards with facility manager on duty. During observation, LPA and facility manager observed a Resident room to have a window above a resident’s bed which would open but not able to appropriately shut and lock, exposing resident to outside elements.
{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20220624123206
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DELTA MANOR
FACILITY NUMBER: 392700769
VISIT DATE: 07/20/2022
NARRATIVE
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Interviews conducted revealed this disrepair item was unknown to staff. On 7-20-22, an additional facility observation and interview was conducted by LPAs which revealed facility's air conditioning unit to be malfunctioning. Based on observation and interview, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation #2:Facility does not provide a safe environment for residents. LPA conducted facility observation including resident rooms, bathrooms, common areas, kitchen, laundry area, storage room, and front and backyards with facility manager on duty. During observation, LPA and facility manager also observed a wall socket without a safety plate guard to prevent exposed socket. Interviews conducted revealed this safety hazard was not known to staff. An additional observation and interview was conducted by LPAs on 7-20-22 which revealed room temperature at 89*F. Based on observation and interview, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

As a result of this investigation, citations are issued under Title 22, Division 6. An exit interview was conducted with Tanya Monge and a copy of this report was left with Tanya. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20220624123206
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DELTA MANOR
FACILITY NUMBER: 392700769
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2022
Section Cited
CCR
80087(a)
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 Buildings and Grounds. (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees, and visitors. The requirement is not met as evidenced by:
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Licensee will read regulation 80087(a) and submit a signed declaration of understanding to LPA by POC due date.

Licensee will repair or replace window and submit photo and video evidence as proof to LPA by POC due date.
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Based on observation and interview, a window in a resident’s room was unable to close and lock appropriately. Additionally, based on observation and interview, facility’s air conditioning unit was malfunctioning as of 7-19-22. This poses an immediate health, safety, and resident rights risks to residents in care.
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Licensee will submit copy of work order repair of air conditioning unit to LPA by POC due date. Licensee to repair air conditioning unit by POC due date.

LPA may conduct POC visit as necessary prior to clearance.
Type A
07/21/2022
Section Cited
CCR
80072(a)(2)
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Personal Rights. (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment to meet his/her needs. This requirement is not met as evidence by:
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Licensee will read regulation 80072(a)(2) and submit a signed declaration of understanding to LPA by POC due date.

Licensee will ensure a plate guard is installed over identified exposed wall socket and submit photo proof to LPA by POC due date.
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Based on observation and interview, Licensee did not ensure a safety plate guard covering for an exposed wall socket in a resident room. Additionally, Licensee did not ensure a room temperature maintained between 65*F and 85*F on 7-20-22. This poses an immediate health, safety, and resident rights risk to residents in care.
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Licensee will ensure a plate guard is installed over identified exposed wall socket and submit photo proof to LPA by POC due date.

Licensee will submit a plan to ensure facility will maintain a temperature between 65*F and 85*F by POC due date.

LPA may conduct POC visit as necessary prior to clearance.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220624123206

FACILITY NAME:DELTA MANORFACILITY NUMBER:
392700769
ADMINISTRATOR:ZUBIATE, LEAHFACILITY TYPE:
735
ADDRESS:1201 W. SWAIN ROADTELEPHONE:
(805) 242-0135
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:14CENSUS: 11DATE:
07/20/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tanya MongeTIME COMPLETED:
03:50 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Facility is not maintained clean and sanitary.
Chemicals are not locked at the facility.
INVESTIGATION FINDINGS:
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5
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10
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12
13
On 7-20-22 at 1:30pm, Licensing Program Analysts (LPAs) Michael Bilger and Renee Campbell arrived unannounced to deliver findings for the complaint allegations listed above. LPA met with Tanya Monge and explained the purpose of the visit. Administrator Leah Zubiate was not present and gave permission for Tanya to sign in her absence. During this investigation, LPA conducted a facility observation on 7-1-22, and interviewed facility manager on 7-1-22. LPA also interviewed Administrator and reviewed facility file documentation including gardening service records. LPAs also conducted a faclity observation on 7-20-22.

Allegation #1: Facility is not maintained clean and sanitary. LPA conducted facility observation including resident rooms, bathrooms, common areas, kitchen, laundry area, storage room, and front and backyards with facility manager on duty. LPA also conducted interviews with facility manager and Administrator and reviewed gardening service documents. During observation, LPA observed facility’s floors and walls throughout to be clean and sanitary. All areas observed did not contain foul odors. Windows and air vents were observed to be clean and in appropriate working order. Kitchen area floors and countertops were observed to be clean and free of clutter. {Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20220624123206
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DELTA MANOR
FACILITY NUMBER: 392700769
VISIT DATE: 07/20/2022
NARRATIVE
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Backyard area was observed to contain grass and shrubbery of adequate size, and not obstructing fire exits or access to adequate outside space for residents in care. Front and backyard grounds were free of clutter, trash, and other debris. Interviews conducted and records reviewed revealed a gardening service was conducted at facility during the month of June 2022. Based on observation and interviews, there is not a preponderance of evidence to conclude this facility is not maintained clean and sanitary, therefore, this allegation is UNSUBSTANTIATED.

Allegation #2: Chemicals are not locked at the facility. LPA conducted facility observation including resident rooms, bathrooms, common areas, kitchen, laundry area, storage room, and front and backyards with facility manager on duty. LPA also conducted interviews with facility manager and Administrator. During observation, LPA observed chemicals and all other toxins to be locked and secured in kitchen and laundry areas, and inaccessible to residents in care. Furthermore, LPA did not observe any other areas of the facility to contain chemicals and all other toxins accessible to residents in care. Based on today’s observation and interviews, there is not a preponderance of evidence to conclude facility does not lock chemicals in facility. Therefore, this allegation is UNSUBSTANTIATED.

An exit interview was conducted with Tanya Monge and a copy of this report was left with Tanya Appeal Rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5